Basic Information
| Provider Information | |||||||||
| NPI: | 1457805020 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STUTSMAN | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11850 BLACKFOOT ST NW | ||||||||
| Address2: | STE 300 | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632369000 | ||||||||
| FaxNumber: | 7632369010 | ||||||||
| Practice Location | |||||||||
| Address1: | 11850 BLACKFOOT ST NW | ||||||||
| Address2: | STE 300 | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632369000 | ||||||||
| FaxNumber: | 7632369010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2016 | ||||||||
| LastUpdateDate: | 08/11/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.